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Rule of thumb in Dermatology
Background
Dermatology in Sub-Saharan Africa faces unique challenges due to the region’s environmental factors, genetics, socioeconomic conditions, and prevalence of infectious diseases. The high burden of skin diseases, often exacerbated by limited access to dermatologists and inadequate healthcare infrastructure, necessitates practical approaches to diagnosis and treatment. Following rules of thumb and adhering to guidelines specifically tailored to the region can improve patient care and outcomes in dermatology.
Rules of thumb
1. Common Skin Conditions
Sub-Saharan Africa sees a wide range of skin conditions, many of which are preventable and treatable if diagnosed early. These include infectious diseases (fungal, bacterial, viral), inflammatory disorders, and skin cancers.
Rules of Thumb
Early Diagnosis in Hyperpigmented Skin:
Skin conditions can present differently in dark skin, so healthcare providers should be trained to recognize subtle signs of disease. For example, erythema (redness) may not be as apparent in darker skin tones, so other signs like warmth and swelling should be emphasized.
Treat Infectious Diseases First:
Due to the high prevalence of infectious skin diseases such as impetigo, tinea, scabies, and leprosy, addressing infections should be a priority in dermatological care. Topical and systemic antibiotics or antifungals are essential.
Focus on Basic Hygiene Education:
Many skin diseases can be prevented or minimized by improving basic hygiene practices, especially in rural areas where infections like scabies or impetigo are common.
Guidelines
WHO Guidelines on Leprosy and Other Infectious Skin Diseases: Recommend early treatment with multidrug therapy (MDT) for leprosy and emphasize mass drug administration in endemic regions. Regular skin checks and treatment of minor infections like fungal infections can prevent progression into more serious conditions.
2. Skin Cancer
Skin cancers, particularly Kaposi’s sarcoma (associated with HIV) and squamous cell carcinoma, are common in sub-Saharan Africa. Albinism also predisposes individuals to aggressive non-melanoma skin cancers due to UV exposure.
Rules of Thumb
Regular Skin Examinations for Albinos:
Individuals with albinism should undergo regular skin examinations to catch early signs of skin cancer, as their lack of melanin significantly increases their risk of UV damage.
Emphasize Sun Protection:
Teach the importance of sun protection, including the use of broad-spectrum sunscreen, protective clothing, and avoidance of peak sun exposure, especially in high-risk populations such as those with albinism.
Biopsy Early Lesions:
Any suspicious lesion or ulcer that does not heal, particularly in sun-exposed areas, should be biopsied early to rule out skin cancer.
Guidelines
WHO and Local Guidelines on Skin Cancer Screening: Stress the importance of early detection of skin cancers, particularly in people with albinism. Where possible, access to sunscreens and skin-protective measures should be improved, especially in rural areas.
3. HIV/AIDS and Dermatological Manifestations
HIV/AIDS-related skin conditions, such as Kaposi’s sarcoma, seborrheic dermatitis, and herpes zoster, are common due to the high prevalence of HIV in the region. Note that opportunistic skin infections in HIV can have atypical presentations and can be severe/difficult to treat.
Rules of Thumb
Look for Cutaneous Markers of HIV:
Skin diseases are often the first sign of HIV infection, especially in untreated cases. Conditions such as Kaposi's sarcoma, molluscum contagiosum, and oral hairy leucoplakia should prompt HIV testing.
Treat HIV-Related Skin Conditions Early:
Conditions like Kaposi's sarcoma or severe seborrheic dermatitis often respond to antiretroviral therapy (ART), so early initiation or adjustment of ART can improve skin outcomes.
Integrate Skin Care into HIV Treatment:
Skin diseases should be treated alongside HIV care to improve the quality of life. Tinea is also quite common. Early treatment of opportunistic infections like shingles or fungal infections can prevent further complications.
Guidelines
WHO HIV Treatment Guidelines: Stress the importance of integrating dermatologic care into HIV/AIDS treatment. Early initiation of ART is recommended, alongside the treatment of skin-related complications like Kaposi’s sarcoma with antiretroviral drugs and other supportive therapies.
4. Atopic Dermatitis and Eczema
Atopic dermatitis (AD) and other forms of eczema are increasing in prevalence, particularly in urban areas. The dry climate in many regions of sub-Saharan Africa can exacerbate these conditions.
Rules of Thumb
Regular Moisturization:
For atopic dermatitis and other xerotic (dry skin) conditions, regular use of emollients and moisturizers is key. Encourage the use of affordable, locally available products like petroleum jelly, coconut oil or shea butter to manage dry skin.
Avoid Irritants:
Advise patients to avoid harsh soaps, detergents, and other irritants that can exacerbate eczema and other skin conditions. Instead, recommend gentle, non-perfumed soaps.
Treat Secondary Infections:
Eczema is often complicated by bacterial infections, particularly Staphylococcus aureus. Address these with topical or systemic antibiotics when needed.
Guidelines
Global and Local Eczema Guidelines: Recommend regular use of emollients to maintain skin barrier function. When necessary, use topical steroids to manage flare-ups, particularly in moderate to severe cases. Education on avoiding irritants is key in management.
5. Fungal Infections
Superficial fungal infections, such as tinea capitis and tinea corporis, are common and easily transmitted, especially in overcrowded living conditions.
Rules of Thumb
Use of Antifungal Creams:
Treat tinea infections promptly with topical antifungals like clotrimazole or miconazole. In more severe cases, systemic antifungals such as griseofulvin may be required for tinea capitis.
Address Environmental Factors:
Educate patients on maintaining clean, dry environments to prevent fungal infections. Shared items like towels or bedding should be cleaned regularly to reduce transmission.
Monitor for Recurrent Infections:
Recurrent fungal infections, especially in children, can indicate underlying nutritional deficiencies or immune suppression, so these should be evaluated.
Guidelines
WHO Guidelines for Dermatophytosis: Recommend the use of topical antifungals for localized infections, with systemic treatment for widespread or resistant cases. Education on hygiene practices is important in preventing transmission.
6. Hyperpigmentation and Hypopigmentation Disorders
Conditions like post-inflammatory hyperpigmentation, pigment problems may include pityriasis vesicolor and pityriasis alba are common causes of hypopigmentation. Vitiligo, and melasma are also found in darker-skinned populations.
Rules of Thumb
Avoid Aggressive Treatments for Hyperpigmentation:
Over-treatment of hyperpigmentation, especially with potent steroids or bleaching agents like Mercury and Hydroquinone, can cause further damage and scarring. Use depigmenting agents with caution.
Sun Protection:
Encourage the use of sunscreen, as hyperpigmented areas are more prone to darkening when exposed to the sun. This is especially important for conditions like melasma.
Monitor for Psychosocial Impact:
Conditions like vitiligo or severe hyperpigmentation can have a significant psychological impact. Offer counselling or support for patients struggling with self-esteem issues.
Guidelines
Global Pigmentary Disorder Guidelines: Recommend cautious use of depigmenting agents and emphasize the importance of sun protection. Psychosocial support should be integrated into the care plan for patients with pigmentary disorders.
7. Scabies and Other Parasitic Infections
Scabies is endemic in many parts of sub-Saharan Africa, particularly in crowded and impoverished areas. Other parasitic skin infections, such as pediculosis, tungiasis (caused by the sand flea)are also common.
Rules of Thumb
Mass Treatment for Scabies:
In endemic areas, mass treatment with ivermectin may be necessary to control outbreaks. Topical permethrin can also be used where available.
Education on Hygiene:
Educate communities on the importance of washing clothes and bedding in hot water to eliminate scabies mites. Regular handwashing and cleaning of personal items are important.
Prevent Tungiasis:
Encourage wearing shoes and maintaining clean environments to prevent tungiasis. Early removal of embedded fleas can prevent secondary infections.
Guidelines
WHO Guidelines on Scabies: Recommend mass treatment with ivermectin in communities with high prevalence rates. Emphasize the importance of improving living conditions and personal hygiene to prevent reinfestation.
8. Tropical Ulcers
Tropical ulcers, which are commonly found in children and young adults, can progress rapidly if not treated. They are often caused by poor hygiene and are associated with malnutrition and trauma.
Rules of Thumb
Clean and Dress Wounds:
Regularly clean and dress ulcers to prevent secondary infection. Use antiseptic solutions like potassium permanganate or iodine to clean wounds.
Address Underlying Conditions:
Malnutrition often contributes to poor wound healing. Nutritional support should be integrated into the management of tropical ulcers.
Early Antibiotic Use:
Treat secondary bacterial infections with antibiotics to prevent further complications such as osteomyelitis.
Guidelines
WHO Guidelines on Tropical Ulcers: Recommend regular wound cleaning and the use of antibiotics for secondary bacterial infections. Prevention strategies should include improving nutrition and hygiene in affected communities.
Conclusion
Dermatology in sub-Saharan Africa requires a tailored approach to address the unique challenges posed by the high prevalence of infectious diseases, environmental factors, and limited healthcare resources. Rules of thumb like early detection, treatment of infections, and basic hygiene education are essential to improving dermatological care in the region. Following WHO guidelines and other local protocols can significantly reduce the burden of skin diseases by promoting mass treatment programs, sun protection, early cancer detection, and better management of HIV-associated skin conditions.
Incorporating dermatological training for healthcare workers and educating communities about basic preventive measures can make a substantial difference in patient outcomes. By integrating dermatology into primary healthcare, increasing access to affordable treatments, and leveraging local solutions, sub-Saharan Africa can better address the region’s dermatological health challenges, leading to improved quality of life and reduced morbidity from skin diseases.
Further readings
- World Health Organization. Leprosy 27 January 2023. Leprosy (who.int) Accessed 13th September 2024
- Johnson MM, Leachman SA, Aspinwall LG, Cranmer LD, Curiel-Lewandrowski C, Sondak VK, Stemwedel CE, Swetter SM, Vetto J, Bowles T, Dellavalle RP, Geskin LJ, Grossman D, Grossmann KF, Hawkes JE, Jeter JM, Kim CC, Kirkwood JM, Mangold AR, Meyskens F, Ming ME, Nelson KC, Piepkorn M, Pollack BP, Robinson JK, Sober AJ, Trotter S, Venna SS, Agarwala S, Alani R, Averbook B, Bar A, Becevic M, Box N, E Carson W 3rd, Cassidy PB, Chen SC, Chu EY, Ellis DL, Ferris LK, Fisher DE, Kendra K, Lawson DH, Leming PD, Margolin KA, Markovic S, Martini MC, Miller D, Sahni D, Sharfman WH, Stein J, Stratigos AJ, Tarhini A, Taylor MH, Wisco OJ, Wong MK. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy. Melanoma Manag. 2017 Mar;4(1):13-37. doi: 10.2217/mmt-2016-0022. Epub 2017 Mar 1. PMID: 28758010; PMCID: PMC5480135. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy – PMC (nih.gov) Accessed 13th September 2024
- Thawabteh AM, Jibreen A, Karaman D, Thawabteh A, Karaman R. Skin Pigmentation Types, Causes and Treatment-A Review. Molecules. 2023 Jun 18;28(12):4839. doi: 10.3390/molecules28124839. PMID: 37375394; PMCID: PMC10304091.
- World Health Organization. HIV and AIDS 22 July 2024. HIV and AIDS (who.int) Accessed 13th September 2024
- Arents BW, van Zuuren EJ, Vermeulen S, Schoones JW, Fedorowicz Z. Global Guidelines in Dermatology Mapping Project (GUIDEMAP), a systematic review of atopic dermatitis clinical practice guidelines: are they clear, unbiased, trustworthy and evidence based (CUTE)?. British Journal of Dermatology. 2022 May 1;186(5):792-802. Skin Pigmentation Types, Causes and Treatment—A Review – PMC (nih.gov) Accessed 13th September 2024
- Mackenzie, D. W. R, Loeffler, W, Mantovani, A, Fujikura, Takao & World Health Organization. Veterinary Public Health Unit. (1986). Guidelines for the diagnosis, prevention and control of dermatophytosis in man and animals / edited by D. W. R. Mackenzie … [et al.]. World Health Organization. https://iris.who.int/handle/10665/61519 Accessed 13th September 2024
- World Health Organization. Scabies 31 May 2023 Scabies (who.int) Accessed 13th September 2024
- World Health Organization. Buruli ulcer (Mycobacterium ulcerans infections) 12 January 2023 Accessed 13th September 2024
